Prescription Drug Access Disparities Among Working-Age Americans

Issue Brief No. 73December 2003
Marie C. Reed, J. Lee Hargraves

orking-age African Americans and Latinos are much more likely than white
Americans to report they cannot afford all of their prescription drugs, according to
a new study by the Center for Studying Health System Change (HSC). In 2001,
nearly one in five blacks and one in six Latinos 18 to 64 years old did not purchase
all of their prescriptions because of cost, compared with slightly more than one in 10
whites. Cost-related prescription drug access problems are considerably higher for
people with chronic conditions,1 particularly African Americans. Regardless of race
or ethnicity, uninsured working-age people with chronic conditions are at particular
risk for not being able to afford all of their prescriptions, with about half reporting
cost-related prescription access problems. Increased patient cost sharing for
prescription drugs will likely increase prescription drug access disparities for
insured African Americans and Latinos, especially those with chronic conditions.

Blacks and Latinos More Likely to Go Without Prescriptions

pending on prescription drugs
continues to increase rapidly in
the United States, reflecting a growing
reliance on drugs to treat a variety of
health problems.Access to prescriptions
varies by race. For example, research
has shown that blacks are less likely
to be prescribed medicines than are
whites with similar health conditions.2

According to results from the
Community Tracking Study (CTS) 2001
Household Survey (see Data Source),
working-age African Americans and
Latinos are considerably more likely than
whites not to fill all of their prescriptions
because of cost concerns (see Figure
1). Overall, about 20 percent of blacks,
16 percent of Latinos and 11 percent
of non-Hispanic whites did not fill at
least one prescription in 2001 because
of cost concerns.

Large Gap for Minorities
with Chronic Conditions

hronic conditions contribute substantially
to racial and ethnic disparities in
health status in the United States, particularly
for African Americans, and are
among the principal reasons why blacks
die at younger ages and at a much higher
rate than white Americans.3 Black
Americans also are more likely to have
multiple chronic conditions.4

Working-age African Americans and
Latinos with chronic conditions were
substantially more likely than whites
to report not having filled at least one
prescription in 2001 because of cost (see
Table 1).More than 30 percent of blacks
and a quarter of Latinos with chronic
conditions didnt purchase all of their
prescriptions in 2001 because of cost,
compared with 17 percent of whites
living with chronic conditions.Workingage
Latinos and blacks without chronic
conditions were also more likely than
whites to face prescription drug affordability
problems. In general, however,
people without chronic health problems
are much less likely to report having
problems purchasing their prescriptions.

Overall, the relative disparity in costrelated
prescription drug access problems
for African Americans and Latinos
compared with whites is fairly similar regardless of the number of chronic conditions:
blacks are about 75 percent and Latinos about
50 percent more likely than whites not to have
purchased at least one prescription drug in
2001 because of cost issues. However, the
absolute disparity or gap—the percentage point
difference between the percent of whites and
African Americans and Latinos with cost-related
prescription drug access problems—is much
greater for those with chronic conditions. This
finding is important because prescription drugs
are critical to ongoing treatment of many
chronic conditions, and lack of access to appropriate
prescription medication can result in
pain,worsening of the condition and increased
risk for other related health problems.

The size of the gap between minorities and
whites in cost-related prescription drug access
problems increases with the presence of chronic
conditions. The gap between blacks and whites
was 5 percentage points for those with no
chronic conditions, 12 points for those with
one condition and 15 points for people with
multiple conditions. Similar, though generally
smaller, gaps were found for Latinos as well.
More than 35 percent of blacks and 30 percent
of Latinos with multiple chronic conditions
did not purchase all of their prescriptions in
2001 because of cost, compared with slightly
more than 20 percent of whites.

Gaps Exist Among Insured
But Not Among Uninsured

ninsured people were more than three times
as likely as those with private health coverage
to have gone without at least one prescription
in 2001 because of cost concerns (see Table 2).
However, previous HSC research shows that
drug-affordability problems are not limited to
the uninsured—about a quarter of working-age
people with Medicaid or other state coverage
did not purchase at least one prescription in
2001 because they could not afford it.5 African
Americans and Latinos are more likely to be
uninsured or to receive their health insurance
through a public program6, and, as a result,
members of these minority groups are more
likely to have problems affording all of their
prescriptions.

Uninsured African Americans, whites and
Latinos were equally likely to report problems
affording prescription drugs. All three groups
had extremely high rates of affordability problems,
particularly among those with chronic
conditions. Regardless of race or ethnicity,
about 50 percent of working-age uninsured
people with chronic conditions reported
cost-related prescription drug access problems.
The rate for uninsured persons without
chronic conditions was about half that level.

Similar to uninsured people, working-age
people with public insurance, including Medicaid
and Medicare, were more likely than privately
insured people to report problems affording
prescription drugs. In particular, publicly
insured African Americans living with chronic
conditions were much more likely than publicly
insured whites or Latinos with chronic conditions
to report problems affording all of their
prescriptions. Even after accounting for socioeconomic
factors such as income, age and
gender that can affect both need and ability
to pay, blacks with public insurance and at
least one chronic condition were a third more
likely than whites with public insurance and
at least one chronic condition to have problems
affording all of their prescription drugs.7
Some possible explanations for this disparity
may include differences in individual and
family financial pressures and resources as
well as regional and individual factors not
accounted for in the model.

Prescription drug access problems are lowest
for the privately insured, regardless of race or
ethnicity.However, significant racial and ethnic
disparities in access to prescription drugs exist among those with private insurance, with the
largest disparities among those with chronic
conditions.Working-age, privately insured
African Americans with chronic conditions
were twice as likely as whites (22% compared
with 11%) not to purchase all of their
prescription drugs in 2001 because of cost
concerns. Privately insured Latinos with
chronic conditions (18%) also experienced
more problems affording drugs than did whites. A prescription drug access gap also
exists for privately insured African Americans
and Latinos without chronic conditions.

There are a variety of explanations for these
disparities, many of which are economic. For
example, employed blacks and Latinos generally
earn less than whites, and they are less likely to
work for employers offering health plans with
generous prescription benefits.And, if offered a
choice of health plans, they may be more likely
to select one with lower premiums—which
generally provides fewer benefits and requires
more patient cost sharing—to increase takehome
pay.8 When income and other socioeconomic
factors are taken into account, the
prescription drug access gap for the privately
insured with chronic conditions closes for
Latinos but not for African Americans.

1 People were classified as having a chronic condition if during the previous two years they had seen a doctor or health professional
for at least one of the following conditions: diabetes, arthritis, asthma, chronic obstructive pulmonary disease, heart disease, hypertension,
cancer or depression.

2 The gap equals the estimate for minority group minus the estimate for whites. Slight differences from estimates calculated directly
from table are due to rounding.

1 People were classified as having a chronic condition if during the previous two years they had seen a doctor or health professional
for at least one of the following conditions: diabetes, arthritis, asthma, chronic obstructive pulmonary disease, heart disease, hypertension,
cancer or depression.

2 Public insurance includes Medicaid,Medicare and other public insurance.

More Disparities?

s private and public payers grapple with rising
health care costs, including those related to drug
price and volume increases, consumers are being
asked to pay more for their prescription drugs
in a variety of ways. Some have higher copayments,
and most plans now include tiered
copayments where patients pay more for brandname
drugs and those not on a preferred list.
Others have prescription drug coverage with
coinsurance, where patients pay a percentage
of the total drug cost rather than a fixed
copayment. Price sensitivity to prescription
purchases is strong, particularly among lowincome
people, meaning that even minimal
patient out-of-pocket costs can result in people
failing to fill their prescriptions.9

African Americans and Latinos are much
more likely to have lower incomes than are
whites, putting them at greater risk for increased
problems paying for their drugs as out-of-pocket
costs escalate. And since African Americans
and Latinos with chronic health conditions are
much more likely than whites to have problems
affording all of their prescription drugs already,
prescription drug access disparities among those
with chronic conditions are likely to increase as
patient cost sharing increases. Rising out-ofpocket
prescription drug costs may undercut
efforts to reduce racial and ethnic disparities in
access to health care, including prescription
drugs,with the greatest effect on reduced access
for minorities with chronic conditions.

Notes

1.

People were classified as having a chronic condition
if during the previous two years they had seen
a doctor or health professional for at least one
of the following conditions: diabetes, arthritis,
asthma, chronic obstructive pulmonary disease,
heart disease, hypertension, cancer or depression.

Sixteen percent of blacks aged 18-64 reported having more than one chronic
condition in 2001, compared with 12 percent of whites and 7 percent of Latinos.
See Supplemental Table 1 associated with this Issue Brief at www.hschange.org
for additional information on chronic condition status by race.

Thirty-nine percent of working-age blacks had public insurance or were
uninsured in 2001. The rate for Latinos was 48 percent. See Supplementary
Table 2 associated with this Issue Brief for additional information on insurance
type and race.

7.

See Supplemental Table 3 associated with this Issue Brief for details
on the results of the multivariate model at www.hschange.org.

Data Source

This Issue Brief presents findings
from the HSC Community Tracking
Study Household Survey, a nationally
representative telephone survey of
the civilian, noninstitutionalized
population conducted in 2000-01.
Data were supplemented by in-person
interviews of households without
telephones to ensure proper representation.
The survey contains information
on about 60,000 people, including
approximately 37,000 white, Latino
and African Americans 18 to 64 years
of age. The response rate was 59
percent. Estimates in the Issue Brief
reflect the percentage of working-age
adults who responded "yes" to the
following question: "During the past
12 months, was there any time you
needed prescription medicines but
didnt get them because you couldnt
afford it?" More detailed information
on survey methodology can be found
on this Web site.